Guest Commentary I Advice to the Young Clinician: Thm Ar& m$ - - PDF document

SLIDE 1

Guest Commentary I

Advice to the Young Clinician:

Thm Ar& m$ Prffismm&mt&mrx

Richard Colgan, MD

he skill of presentation is funda-

mental to practicing the art of med-

• icine. It is important to effectively

convcy the logic behind your rctions, whether in writing or oral presentation.

I repeatedly see stndents, residents, and

even physicians present in a haphazard

r,vay. These people often have intelligent

contributions to make to the discussion,

but their nlessage is often lost in rhe

confusion ar.rd disarray of ideas. Wich

this editorial, I ainr to underscore some

• f the crucial eler.nents of a good pre-

sen[ation so that others will apprer:iate horv rruly gil'ted you are.

E)(PECTATIONS

The first step is to understand what is expected ofyou and to know the basics about r'vhat factual infornration rlust be conveyed in this exchange. It is eqr,rally

as important to kuow who rvill be the

recipient of your lllessagc and rhe spe-

cific format they prefer. Be sure you

knor.v the parlance of each specialty and che differences among the specialists- eg, a presentation to a cardiologist rvill

nor be thc same as a presentation to an

• bsterrician simply by the nature of their

proGssional differences.

When presenting patient informa- tion to a cardiologist, you rnLrst be sure

to knorv all the coronary artery disease

(CAD) risk factors of your patient ls

rvell as previous cardiac catheterization

• details. Ifyour patient has chest pain,

be sure ro include the descriptors of angina too. Be mindful how often pa-

tiencs wich CAD present without clas- sical angina. I frequently hear patients

underscore pain while waving their hand from left to right in an attempt to

dismiss my concern. On the other hand, an obstetrician is going to want to know your patienti last menstrual period, men- strual cycle characteristics, and gestarional history. Horvever, regardless of the specialty,

there are alrvays sonre colnnlon critical

facts that need to be addressed. For ex-

ample, understand upfr-ont if you are being asked to give a full comprehensive prescntation or a 1-nrinute briefupdate.

EFFECTIVE PRESENTAII(]N

Young hcalers rypically get a briefrun- dor,vn on how to properly present a pa- tient and are encourased to describe this infornration in a certain order. Often this education is inadequate and they learn shordy after how they screwed something

up-eg, horv they should have presented

the history of present illness or what they should have left out of the analysis.

It is irnportant to learn how to pres-

ent a patienr efTiciently and thoroughly for 3 reasons.

. Deuelop a methoil. Per SirWilliam Oslert recommendation, if you

consciously do things the same way each tirne, you are less likely to for- get something of significance. If you alrvays order your presentation

as chief cornplaint, history of pres-

ent illness, past medical history, current medications, and then aller-

gies, you are less likely to ever for-

get to ask your patient ifthey are allergic to sonrething and even less likely co prescribe a medicine that nray result in a fatal allergic reac- tion. Implicit for a good presenration is that you have performed your evaluation in a thorough manner and that you have fol- lowed a proper nrethod. For exaurple, present the history with proper rnethod

by recounting the patient's story in a

chronologic.rl .rnd descriptive tnanner. Start by referencing when the problen-r

began (ie, when the patient was last weil) and present the physical exam results by

logically reportir.rg information from

head to toe.

. Prcsent clearly ad concisely,lt rs important to present effectively so

that your listener-rypically a fellow

clinician-can clearly understand

what you did or plan to do. A good presentation will enable a subse- quent care provider to easily pick up where you left offand provide a smooth transition to enable the best possible patient care. Note:A good presentation is not a cornprehensive data dump,'uvhere you look to im-

press the listener with the facr that

you asked everything. A good pre-

sentation is giving the listener the significant information they need to

know so chey are able to understand what you learned. have input into the case, and perhaps eventually take

• ver that personi care.

For example, an improper patient

presentation is calling your atrending at

2 AM to give an overly thorough de- scription of your stable patientt entire health history, including his banana al-

• lergy. (This actually happened to me!)

Inscead, you should succincrly give your

listeners the information they need to make their orvn independent assessment

as to rvhat is going on with the patient. www.consultant360.com . October 2Ol4 . CONSULTANT 755

SLIDE 2

Guest Com mentary

This prrt is slightly trickl', bcc:rusc it inplies thrt you knorv all of tl.re perti-

neut positive rncl nccativc cluestions atrd iluswcrs to inclr-rde in yottr presenlrr-

tion-s4rich as a yoLlnll hea)el vott nuy

not.You rtrc leanriug these rs yoLt ptlrstle

• voul tlaining rncl rvill cotrtinue ro le:rt'tr

nrorc ancl urore each diry olyour clrecr. Like lny othel skiil, rhe discovery arrd recognition of significllrt iufirrtrr:rtion

conres u'ith practicc.

. Pyescnt utell.'fhc listerer is oftcn

going to judgSe yor.rr corllpetence

based in part ort hotv u,ell )'oll Llse

the language of meclicinc-in short,

hos' rvcli ),ot-r prcsented.You clu be

brillilrt yet prescnt badly-ancl

your ulerltor u,ill think you to be disolsanized or incompctent. The soolrcl you lllastcr the skill of pre-

sentation, the sooner you rvill ittr- prcss all of thosc rvho listen to 1,ou and carn rccoqnitiou as sol)leone

u,ho is otqanized atrd coherent.You

.,vi11 nrorc likely bc viewed ils colrl-

Petellt.

RULES F(]R AN EFFECTIVE PRESENTATION

' Use ysvv patient's words. Therc is

alna,vs a chicf conrplaint and this is best given in the patie-uti or,vn

uords .utd l)ot youl J\sc\snlerrt of rvhat he or she meant. For exrtrnple, the parient sricl,"I couldn't brcathe"

is better tlun your rrssesslrrcnt, "The

p:rticnt presenteLl rvith sl-rortness of breath ol clysprtea."

. CarefuIly outline the history of prcs-

ent illness (HPI). This is the nrost inrportant part of the entire history,

so you want to be very catc'ful ch:rc

vou attend to it l,cll. Begirr by dc- scribing the patienc: "This is the lilst r,uriversity hospiral adnrission

fbl this 2.|-year-oId Africau Arueri-

can fenrale rvho 'nvas u,eli until ),es-

rcrdly\ adrttission u'hen shc troted

she couldn't brcatl-re."

The HPI should r-ead like a nervspaper

• lrriclc. uhercitt tltc Irrost ittrpottnt:t rett-

tcncc-or the lcad-is first ancl then

subsequently follorved by utore dctailed inforrnation of lesser irupoltance. Likc a eood journalisr, clo trot bury your lelcl.

Do not hide rr critical piccc of historicril infornntion tirrther dorvn in the body

• f the report,'nvhcn in fact it is crucial to

urclelstalclilg thc p;rticntls illness.

For: ex;rurple, if your- lrarient 'n'nas llso suflering fionr ltt unclerlying m:tlierrancy, wxs or1 orrl contraceprive thellpy, artcl her slrortness oibrcath occurrecl sirtrulta-

ncously rvith thc' abrupt otrset of rr dlv cough on thc d:ry rftcr her lone ailpl:rnc flight, r,vhich rv:rs 1 rveck rttcr she hlcl her left leg placed in r c:rst fbr :r chip ii-nctulc of tl'rc ankle that occurred rr,hilc skiing, sa1' so. She ntrv havc pttlnrotrarv r'rrrboli, lnd ls yotr presclrt voul' pilticltt

in a losic:rl rnd prioritized flshion. you

rvil1 hclp vour collertgtte bctrer urtdet'-

st.rncl hor'v 1.ou lerched tlut couc1rtsior-t.

Althongh each piecc of ir.rformatiotr

could rheoretically be c:tteqorized under rnln1, diflercnt p;rrts of the patientls his- tor\., they arc deteils th:It al-c extretuely

inrportllt in cleciphering thc case. It is

r.rp to you to rccognize therr as such rnd

givc thenr to voLlr listener rs coherentll, and concisely as possible. Rcruc-nrbel to prcsent your clata tne- thodicrlly and cluotroloeicrlll, in a con- tinuurn fl'onr rvhen the patient felt rvell ro the pre\cnt sick corrditiorr. . Personalhr ask tlrc patient about

nreilications and allergies. Follorv

vour HPI rvith past meclical historl;

nredicatior-rs. and rllergies. Even if rr

nlll'sc or meclic:rl assistant hls fillecl this irrlbrmltion in ltol yor-1, yoll

shor-rld personally ask erch paticnr

about mcdicltiotrs ancl allersies. l)o this cverl' title von see r pxtient, Ii)[ the rcst of y'otu- liG.To not do so is brd practice, and n-ristakes rrrade by

r-nissing this opportur-rity ro collect

:urd/or contlmr vah-rablc patierrt in- tbrnr:rtiorr c:trr ltlrrtt vout' p.tticttt

and ,vottr crt-eer.

This is a good terllplate tbr the most csscrrtial conlponents of the sr-rbjective portioll of your plescnlation. Reruetuber to !ollecr rr rrrrrch intbrtttatiort es porsi-

bie . lf askecl, l,ou shoulcl bc pr:cpared to

provide sr-rppleurctrtrl f:rcts fi-orrr the

lrrnrily l-ristoly socill histoly, atrd revicu'

• f s,vstculs, rvhile re:rlizirtg thrlt Pertinent

infbrrurtion should alrcady hlve beerr

rnentioned in the HPI.

. Vital signs are uital.l)egin the ob-

jectivc exrurr rvirh y'our pxtient\ genenl appexrrncc follorved by his

• r her vit:rl sisns.The general ap-

perrrance should be sttcir thlt ),ott

could easill, pick the p:rtient ti'our a ,'t'ou.l of pcoplc or'.t u'.titittq tr>ottt. In thct, vit.i1 signs rtc rreltably the nrost inrportxDt signs under tl-re ob- jcctive pr-rrtiott oiyottr l)reselltiltiotl eiong u'irh rhe general appeararlce.

Yet, thc'se 2 descriptols rn: ottetr civcrr little to no ll)clrtioll. Yon can be brief-, 1or e-xanrple:The pa-

tient "looks to be in no .lcute distress

anci vital signs are srable."Just be surc to

include sonre rccorr-tition of this valuable

• infomution. Note:As rvith the l-ristorv
• Iprcscnt il]ttc.s. ut.tke sLlrc to tttt'ntiotr

siqnific:rnt vital signs r'vhen tl-rey :rpply dilectlyi If our rhcoretical paticnt s,as sufTering fi-orn puh'nonary cnrboli, rr'e s,onlcl s,lnt to specific:rlly tuentiott her respiratory ratc, follorvcd by hcr pulse

• xirletrl, reacling.

. Every great healer knows the valte

• f (appropriate\t) touching ),our pa-

,iert. Alrnosr cvery pltiettr vou care for in rhe clinical pr.rctice of medi-

cine, ccltainly in priruary clre tued- icine, shor,rld have his or he:: hcarl and lunss ruscultltec-I.T1-rcr-e rlay be solrle particular e\cePtiolts !o this rule, but nrost physicians should lis- terl to their patienti heart rrnd lungs

rt cach visit.This is not lrecessrrily

[or: thc pur-posc oidiscovcritrg sottte

pathololry-not to scarch fot' a

nrid-systolic click or pick up subtle bronchophor-r1'-but so 1ror,r uray lay your hancls on the prtient.

You shotrld go out of your wxy to practicc a "lrying on of the hancls." It is part of a therapeutic, pr:otessiorul inti- nracl' betrvcen physician :rnd paticnr, a

conre)rallce of colrpassior-r for the per- son voll ar-e pr<>vidine clre. It is l siqn, lt

a mininttru, of kinclLrcss.

756 CONSULTANT. October 2014 . www.consultant360.com

SLIDE 3

. Conuneflt on "the othel'or any-

thing else in the physical exam that may be notewoythy. Iu our plrierrt

above, you may also conunclrt if you hear a fixed splitting of rhe second

heart sound as might be heard in

nrassive pulrnonary enrboli.

. -dssess and make a plan, After your

• bjective exanr, conres the hardest

part for physicians in rraining: the

assessnrent ancl plan. It is the most

challenging, for the iess clinical trainir-rg you have experiencecl rhe

less abiliry yoll possess to develop ir

broad differential diagnosis.The as-

sesslrrent should not be a repetitiou

• fyour history and physical. It

should be your synthesis ofa rvork- inu diaguosis, evcn ifyou do not

krorv u,hat is going on.

For exanpie, if you are not sLlre

',vhat is causing your patienti shortness

• f breath, you should list what you

knorv as fict: "Problenr number I is dyspnea, etiology unclear. Problenr nunrber ? is recent left leg fracture.

Problenr nurnber 3 is prc'vious codeine anaphylaxis, and problerr nut.t-rber ,l is health maintenance-it is noted tl-rat it

has been severll years since hcr last pap

snrear." Call your pxtienc's problem rvhac you unclelstand it to be at the

• tinre. C)ther exanrples nrieht be "chest

pain, eciology unclear" or "vesicular

unilatelal T5 dermatomai eruption, eti-

• logy unclear."

By stating your working diagnosis, you

knor.v lvhere you are and are given a lead

as to horv ro proceed. Also, it conununi-

cates to yotrr listener that rhe gears .rre

tulning, and vou are thinking along a

logical train ofthought, even ifyotr have not yet arliv'ed at the xnswer.

' Implement ),otn plan. This plan

should bc congruent with your as-

• sessnlent. If you have mentioned 3

lctive problems in your assesslrent, you should have 3 accivc plan iteurs.The plan also inch-rdcs pa- rierrt cduc:rrion gorls. prescriptior)

• f rnedications, and diagnostics,

including any addition:rl studies you rvor-rld like to ordcr.

In addition, every tinre you see pa-

tienrs it is rvise to ir.rclude in your plan lvhar they can do to lielp therlselves, as r.vell as when they should contact you again and return for care. Sorne varia- tions to this apply. lfyou rre seeing a pa-

tient for an acute or sick visit, there

should be solne nrention of health main- tenance under his or her assessruent or

pl:rn.This is your opportuniry to inquire

ifhe or she is up to date on age-appro-

priate health screeninss (eg, an annual well-rvonran exaur). If not, part of your plan should be a recornrnendation thar

your patient also co[sider r-naking an ap-

pointnent for r,vhatever heaith screening

exanrs thcy require.

In continuing wirh the example of our

clinical case of a young rvornan with

shorcness ofbreath, our plan nright have

the tbllowing conlponents:

THIt{GS TO AV()ID

Conmron nristakes occur as presenta- tions becourc disorganized and messy. Yolrr preselrtation should start with the subjective (What did yorlr parient say?), ftillowed by the objective (What did you

• bserve, auscultate, palpate, percuss-

6nd?), follorved by your asscssnrent (-What

do you think is going on?), and finally, your plan (Whar are you going to do?).

Guest Commentary I

A cornuron r.rfstake that all physicians in tr-aining and young physicians n'rake is soins from topic to topic, or from S to

P to A to O to S to O to S again, back

to P, etc. My advice to you is to tell

thenr the S, the pertinent S, and noth- ing but the S.Then pause. Indenc your preselltatiolr so the listener knows you

are no\v lcaving "the land of S," for the "lancl of O."When you get ro O, always begir-r rvith general appearance, fol- lorved by those nrost vital signs. (They are vital!)

When young healers get to the as-

sessrltent, they often want lo repeat the S ancl O again.You lnusc fight hard not co do this and continue on to A and P

by laying out the patient's problems

and attenrpted solutions. My advice to

thc young heelcr is to practice your prcscntrtion skills as often as you can

and be thankful when a senior clinician "pokes you in the ribs" and tells you to do it difTerently.

• Explained n1y concern for liG-

threatening pulnronary enrboli to You nrust always strive to be the best patient; she agrecs to enlergency conrmunicator of medicine possible. In departnrent transfer by ambulance the end, the patient will be better served, for considemdon of irnasin€l srudies you rvill be a berter physician, and you to rule out puhlonary emboli

will be vierved in a rnore mature light. I

• Continued lronweight bearing and

use of crutches in light of her re-

Richard Colgan, MD, rs a professor at

ccnt leg fracture tha Urtiuersitl, of Marylaxl Sclnol of Medi-

• Avoid codeine given allergy to

dne itr Baltimorc, MD, and tlrc uict dmir of

sanre; consider nonsteroidal lnti-in- nrcdical sttrdcnt efurcation and clinical opcra-

flarrnrratory for pain relief

ti<tns in tltc Departrnent ttf Family and Com-

• Patient urged to make a follow-up ntwtity Mglli6ine. Hc is also the author of

[':ifi'"'date

for.a well-rvorn-

tlJild:r,#ealer:

• n the Art of

Physicians should also include recorn- fUnffftn READING AND RESOURCES nrendarions about diet, exercise, and stress . Mccee S. Oral case presentation guide- r-rnder their plan.

• lines. University of Washington. http://

iquemedcases.files.wordpress. coml 2Ol 7 lO2l oral-case presentation-gu ide- lines,pdf.

. Oral presentation on rounds. Loyola Univer-

• sity. wvwv.medicalvideos.us/play.

php?vid=740.

. Selzer R. Leffers to a Young Doctor Boston,

MA: Mariner Books, 1996. Groopman J. How Doctors lhlnk. Boston, MA: Mariner Books, 2008.

For past Guest Commentary visit the archives on www.consultant360.com.

www.consultant360.com. October 2Ol4 . CONSULTANT 757